Nephrolithotomy

Nephrolithotomy

Nephrolithotomy is a surgical operation that is undertaken to remove kidney stones which are too large, hard or complicated to be handled using non-invasive procedures such as shock wave lithotripsy or ureteroscopy. Its use is usually recommended in stones that are above 2 cm, staghorn calculi or stones that are linked to abnormal anatomy.

Nephrolithotomy surgery

Nephrolithotomy is a surgical practice which is applied to treat big stones of kidneys. It may be done in the form of Percutaneous Nephrolithotomy (PCNL) or Open Nephrolithotomy. Today, it is a standard and most frequently used procedure of PCNL.

Procedure:

Anaesthesia

• General anaesthesia is used to ensure that the patient is comfortable and immobile during surgery.

Positioning

• Patient is typically put in a prone (face-down) position or in some centers, a modified supine position.

Imaging Guidance

• Ultrasound or fluoroscopy is implemented to find the kidney and detect the stone.

Skin Incision

• One makes a small (0.51 cm) incision in the flank area.

Creating the Access Tract

• A needle is inserted into the incision into the collecting system of the kidney.
• A guidewire is placed.
• To insert the nephroscope, the tract is dilated by the use of metal or balloon dilators to enable the insertion.

Nephroscope Insertion

• The kidney is introduced to a nephroscope (flexible or rigid).

Stone Fragmentation

Stones are broken using:

• Holmium laser
• Pneumatic lithotripter
• Ultrasonic lithotripter
• Stone pieces are eliminated with the help of suction or forceps.

Stone Clearance Check

• The surgeon examines the calyces to be sure that no fragments were left behind.

Tube or Stent Placement

• Drainage can be done by inserting a nephrostomy tube.
• A few of the cases involve a PCNL that is tubeless and has a single internal stent.
• Selected cases undergo totally tubeless PCNL.

Closure

• The minor incision is sewn up by use of a simple suture or dressing.

Open Nephrolithotomy 

Procedure:

• General anaesthesia is given.
• The kidney is exposed by making a larger flank incision.
• Kidney is moved about, and nephrotomy (kidney opening) is made.
• Stones are removed manually.
• The incision made on the kidney is sutured.
• Drains may be placed.
• Layers of the flank incision are ratched.

This has been left to very complicated cases or anatomical problems that PCNL cannot be conducted.

Nephrolithotomy recovery

The outcome of recovery in nephrolithotomy varies according to the type of procedure performed; that is, Percutaneous Nephrolithotomy (PCNL) or Open Nephrolithotomy. PCNL is also least invasive and its recovery is much faster.

Recovery after Percutaneous Nephrolithotomy (PCNL)

Hospital Stay

• Typically 1–3 days.
• Observation of urine flow, hemorrhage and evidence of infection.

Pain & Discomfort

• The pain in the flank and burning during urinating is typical within several days.
• The pain can be treated normally using oral painkillers.

Urine Color

• Light-blooded urine (hematuria) during 24-48 hours is normal.

Nephrostomy Tube / Stent

• Within 12 hours (1-2 days), nephrostomy tube (when inserted) is removed.
• Ureteral stent can stay in 1-2 weeks and be taken out in OPD.

Activity

• Light activity from day 2–3.
• Return to full activity in 1 to 2 weeks. 
• Avoid heavy lifting and strenuous activity for 2 to 4 weeks. 

Diet

• Start with fluids, advancing to a regular diet as tolerated. 
• Take a lot of water (2-3 liters/day unless limited).

Follow-Up

• Ultrasound/X-ray in 1-2 weeks to determine the clearance of the stones.
• Stent removal if placed.
• Follow-up metabolic assessment to avoid recurrence (long term follow-up).

Post-operative Open Nephrolithotomy

Hospital Stay

• Normally 5-7 days because the incision is bigger.

Incision Site Healing

• Increased flank incision can lead to increased pain.
• Sutures/staples come off 10-14 days.

Activity

• Go back to light activities in 3-4 weeks.
• Typically possible to be fully active after 6 weeks.

Urine & Drainage

• Marginal hematuria within few days.
• It can take 1-2 days in drains based on output.

Food & Liquid Intake

• Normal diet after bowel functioning.
• Fluid consumption promoted.

Nephrolithotomy complications

Nephrolithotomy (particularly Percutaneous Nephrolithotomy (PCNL)) is considered to be safer, although such operation, as any surgery, is not devoid of threats. The complications may be mild or in some rare cases, severe.

• Bleeding
• Infection and Sepsis
• Injury to Kidney or Surrounding Organs
• Urine Leakage
• Residual Stone Fragments
• Blood in Urine
• Thoracic Complications
• Renal Function Changes
• Perforation of Collecting System

Best hospital for nephrolithotomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Nephrolithotomy is the gold standard and most efficient surgical procedure for the management of large, complex, or staghorn calculi especially in the form of Percutaneous Nephrolithotomy. It has high stone-free rates, the least invasiveness, less pain, and quick recovery than the open surgery. Even though such complications like bleeding, infection and residual fragments may arise, majority of them are mitigable when handled with an appropriate surgical intervention and after surgery procedure. All in all nephrolithotomy is a safe, consistent and tested operation to deal with difficult kidney stones and to restore normal kidney functionality.

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FAQ

Is nephrolithotomy painful?

• Post PCNL pain is normally mild to moderate and managed with drugs. The postoperative pain is more in the case of open surgery as a result of the bigger incision.

Am I going to require a stent or nephrostomy tube?

• Sometimes yes. It can be drained with a ureteral stent to be removed.
• In a few instances, a nephrostomy tube may be used to drain urine 1-2 days.

Should I expect blood in my urine after surgery? 

• Yes, mild hematuria is normal in 1-3 days after PCNL. When there is persistent or heavy bleeding, it ought to be assessed.

Is it possible to have kidney stones despite surgery?

• Yes. Nephrolithotomy involves excising existing stones but not the ones to come. Recurrence can be reduced by metabolic assessment, increased fluid intake, and dietary modifications.